GUIDELINE Withholding and termination of resuscitation of adult cardiopulmonary arrest secondary to trauma: Resource document to the joint NAEMSP-ACSCOT position statements Michael G. Millin, MD, MPH, Samuel M. Galvagno, DO, PhD, Samiur R. Khandker, MD, Alisa Malki, BA, and Eileen M. Bulger, MD, for the Standards and Clinical Practice Committee of the National Association of EMS Physicians (NAEMSP) and the Subcommittee on Emergency ServicesYPrehospital of the American College of Surgeons’ Committee on Trauma (ACSCOT) AAST Continuing Medical Education Article Accreditation Statement Disclosure Information This activity has been planned and implemented in accordance with the Es- In accordance with the ACCME Accreditation Criteria, the American College of sential Areas and Policies of the Accreditation Council for Continuing Medical Surgeons, as the accredited provider of this journal activity, must ensure that anyone Education through the joint sponsorship of the American College of Surgeons in a position to control the content of JTraumaAcuteCareSurgarticles selected for and the American Association for the Surgery of Trauma. The American CME credit has disclosed all relevant financial relationships with any commercial College Surgeons is accredited by the ACCME to provide continuing medical interest. Disclosure forms are completed by the editorial staff, associate editors, re- education for physicians. viewers, and all authors. The ACCME defines a ‘commercial interest’ as Bany entity AMA PRA Category 1 Creditsi producing, marketing, re-selling, or distributing health care goods or services con- sumed by, or used on, patients.[BRelevant[ financial relationships are those (in any The American College of Surgeons designates this Journal-based CME activity for amount) that may create a conflict of interest and occur within the 12 months pre- a maximum of 1 AMA PRA Category 1 Crediti. Physicians should claim only the ceding and during the time that the individual is engaged in writing the article. All credit commensurate with the extent of their participation in the activity. reported conflicts are thoroughly managed in order to ensure any potential bias within the content is eliminated. However, if you perceive a bias within the article, please report the circumstances on the evaluation form. Please note we have advised the authors that it is their responsibility to disclose within the article if they are describing the use of a device, product, or drug that is not FDA approved or the off-label use of an approved device, product, or drug or unapproved usage. Disclosures of Significant Relationships with Objectives Relevant Commercial Companies/Organizations After reading the featured articles published in the Journal of Trauma and Acute by the Editorial Staff: Ernest E. Moore, Editor: PI, research grant, Care Surgery, participants should be able to demonstrate increased understanding Haemonetics. Associate editors: David Hoyt, Ronald Maier, and Steven Shackford of the material specific to the article. Objectives for each article are featured at the have nothing to disclose. Editorial staff: Jennifer Crebs, Jo Fields, and Angela beginning of each article and online. Test questions are at the end of the article, Sauaia have nothing to disclose. with a critique and specific location in the article referencing the question topic. Author Disclosures: Michael G. Millin: Payment for development of presentations (National Wilderness EMS Medical Director Course); annual Claiming Credit meeting travel/accommodations (National Association of EMS Physicians); To claim credit, please visit the AAST website at http://www.aast.org/ and click on payment as medical director for BWI airport fire and rescue (Maryland Aviation the Be-Learning/MOC[ tab. You must read the article, successfully complete the Administration). Samuel M. Galvagno: Payment for development of educational post-test and evaluation. Your CME certificate will be available immediately upon presentations (Society for Critical Care Medicine). receiving a passing score of 75% or higher on the post-test. Post-tests receiving a Cost score of below 75% will require a retake of the test to receive credit. For AAST members and Journal of Trauma and Acute Care Surgery subscribers there is no charge to participate in this activity. For those who are not a member System Requirements or subscriber, the cost for each credit is $25. The system requirements are as follows: Adobe\ Reader 7.0 or above installed; Internet Explorer\ 7 and above; Firefox\ 3.0 and above, Chrome\ 8.0 and above, or Safarii 4.0 and above. Questions If you have any questions, please contact AAST at 800-789-4006. Paper test and evaluations will not be accepted. J Trauma Acute Care Surg Volume 75, Number 3 459 Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. J Trauma Acute Care Surg Millin et al. Volume 75, Number 3 ABSTRACT: In the setting of traumatic cardiopulmonary arrest, protocols that direct emergency medical service (EMS) providers to withhold or terminate resuscitation, when clinically indicated, have the potential to decrease unnecessary use of warning lights and sirens and save valuable public health resources. Protocols to withhold resuscitation should be based on the determination that there are no obvious signs of life, the injuries are obviously incompatible with life, there is evidence of prolonged arrest, and there is a lack of organized elec- trocardiographic activity. Termination of resuscitation is indicated when there are no signs of life and no return of spontaneous circulation despite appropriate field EMS treatment that includes minimally interrupted cardiopulmonary resuscitation. Further research is needed to determine the appropriate duration of cardiopulmonary resuscitation before termination of resuscitation and the proper role of direct medical oversight in termination of resuscitation protocols. This article is the resource document to the position statements, jointly endorsed by the National Association of EMS Physicians and the American College of Surgeons’ Committee on Trauma, on withholding and termination of resuscitation in traumatic cardiopulmonary arrest. (J Trauma Acute Care Surg. 2013;75: 459Y467. Copyright * 2013 by Lippincott Williams & Wilkins) KEY WORDS: Termination; withholding treatment; trauma; cardiopulmonary arrest; EMS. n 2003, the National Association of EMS Physicians (NAEMSP) ED procedures, therefore, is not relevant to this article. The Iand the American College of Surgeons’ Committee on Trauma science discussed in this article is purely focused on the patient (ACSCOT) published a joint position article for withholding or that has no identified signs of life and has limited chances of termination of resuscitation (TOR) of patients in cardiopulmonary survival, regardless of the care provided to the patient after arrest caused by trauma1 (Table 1). This resource document sup- arrival to an acute care facility, such that the risks of resusci- ports two new positions (Tables 2 and 3) jointly endorsed by tation and transport outweigh any potential benefit. NAEMSP and ACSCOT on withholding resuscitation and TOR in traumatic cardiopulmonary arrest.2,3 It should be noted that while the previous position considered the concepts of ‘‘with- holding’’ and ‘‘termination’’ collectively, the new positions refer PATIENTS AND METHODS to these concepts separately. Furthermore, while there have been no changes to the withholding position, resulting in a reaffirmation The development of the updated TOR protocol and of this position, evolution of the science has resulted in revisions this resource document began with a structured review of the to the TOR position. literature regarding the topic of resuscitation in traumatic car- Although the unbundling of these two positions may diopulmonary arrest, focusing on articles that pertain to the seem to be mere semantics, there are scientific and regulatory constituents that determine the outcome of the arrest. reasons to separate these two positions. The withholding po- We began with a review of the literature that was used to sition includes notation regarding a lack of ‘‘Iorganized support the 2003 position article. We then initiated PubMed electrocadiographic activity.’’ The determination that a patient and EMBASE searches of the English-language literature does not have electrocardiographic activity requires checking for using the key words: cardiopulmonary arrest in trauma, ter- a pulse and placing a monitor on the patient. In some emergency mination of resuscitation, timing of arrest, rhythm analysis, medical service (EMS) systems, it may be possible to perform vital sign assessment, and emergency department thoracotomy. this action and then withhold resuscitation. However, in some All articles deemed to be relevant to the topic were reviewed, systems, this activity may be considered a part of patient as- and a draft position, based on the supporting literature review, sessment, which defines the initiation of patient care and thus was formulated. This position was then sent for review and defines that resuscitation has already begun. Therefore, in these further refinement by the board of directors of NAEMSP and the systems, it may be more appropriate to use a TOR protocol than a EMS subcommittee of the ACSCOT. Thus, the levels of the withholding protocol except in cases when the patient is clearly evidence of these positions are a combination of an analysis of dead such as decapitation or hemicorporectomy.